- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,897.79 / $4,897.79
| Facility | | $3,388.44 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $3,801.89
| Professional | | $2,454.71 | $3,019.95 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,715.35 / $3,715.35
| Facility | | $741.31 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,548.13 / $3,715.35
| Professional | | $2,344.23 | $3,548.13 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,630.78 / $4,073.80
| Professional | | $2,238.72 | $3,630.78 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,897.79 / $8,128.31
| Facility | | $3,388.44 | $4,897.79 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $3,890.45
| Professional | | $2,454.71 | $3,090.30 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $4,570.88
| Professional | | $2,238.72 | $3,388.44 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,548.13 / $4,897.79
| Professional | | $2,884.03 | $3,548.13 | $4,897.79 |